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THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM.

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CLAIM FORM

Motor Vehicle

The Company does not admit Liability by the issue of this Form. It is

issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER

OFFICE USE ONLY

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Policy Number Client Reference Number

Claim Number

Name of Insured

Address Postcode

Your Business’ ABN Percentage Input Tax credit entitlement for GST

Phone No. Occupation

Are you the sole owner of the insured vehicle? Yes No

If No, name of other interested parties INSURED

( )

CLAIM FORM

Motor Vehicle

THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM.

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We need personal information about you to assess your claim. We will, where relevant, disclose your personal information (other than sensitive information such as health information) to your adviser (and any licensee or broker he or she

represents), to other insurers, insurance reference bureaus, to our service providers (including loss adjusters and investigators) and our business partners for this purpose;

Where relevant, to assess your claim we will also disclose personal information, including sensitive information about you such as health information, to medical practitioners, other health professionals, other insurers, reinsurers, legal

representatives and other consultants. By signing this claim form, you consent to those organisations and other professionals collecting, and us disclosing sensitive information about you for this purpose;

A list of the type of service providers, business partners and consultants we commonly use is available on request, or on our website - go to www.zurich.com.au and click on the Privacy link on our home page;

If you do not provide the requested information or consent to its collection and disclosure as described above, the assessment of your claim may be delayed or we may not accept the claim;

We may also disclose personal information about you where we are required or permitted to do so by law;

In most cases, on request, we will give you access to the personal information we hold about you;

If you would like to find out more, you can contact us by telephone on 132 687, e-mail us at Privacy.Officer@zurich.com.au or write to “The Privacy Officer” at Zurich Financial Services Australia Limited, PO Box 677, North Sydney, 2059. Please provide details of your policy number/s and/or claim number where known.

PRIVACY

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Page 3 of 6

Make & Model Year Colour

Rego No. Engine No. Chassis No.

Class of Vehicle Sedan or Station Wagon Light Construction or Earthmoving Plant Van or Utility up to 2T Heavy Construction or Earthmoving Plant Rigid Vehicle over 2T and up to 5T Trailer

Rigid Vehicle over 5T and up to 10T Other Declared use on registration (Private or Business)

Trailer Details (if applicable)

Make Type Year Rego. No.

TARE WEIGHT

INSURED VEHICLE

For Parked or Unattended vehicles, Driver = Vehicle Custodian at the time of loss.

Surname Given Name(s)

Address Postcode

Phone No. Date of Birth Age Sex

Male Female

Current Driver’s Licence No. Expiry Date Years Licenced

Name of Registered Owner of the Vehicle

Are you an employee? Yes No If not, state relationship

Have you had any traffic convictions and/or traffic offences or been involved in any motor vehicle accidents in the past five (5) years? Yes No If Yes, please give details

Did you consume any alcohol or take any drugs during the 12 hours prior to the accident? Yes No If Yes, state how much and when

Did you undergo a breath test or blood test for alcohol or drugs? Yes No If Yes, what was the result

Did you refuse to undergo any of the above tests? Yes No

( ) DRIVER

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Was your vehicle damaged? Yes No Was your vehicle towed away? Yes No Have you obtained a repair quote? Yes No Amount $ (Attach Quote) Where can the vehicle be inspected (Full address)

Phone No.

Show the damaged areas to your vehicle on the following diagram ( )

DAMAGE TO INSURED VEHICLE

Date Time AM/PM Vehicle Use: Business Private

Day of the Week Mon Tues Wed Thurs Fri Sat Sun

LOCATION: Street Suburb Postcode

How did the accident happen

Please draw a plan of the accident. Show the nearest cross street; street names; centre of the roadway; direction and location of vehicles; location of traffic control signals and any other useful information.

Indicate your own vehicle as

A

Indicate any other vehicles as

B

ACCIDENT DETAILS

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Who do you consider was at fault? Myself Other Driver Other If other, why?

Estimated speed of Your vehicle just before the accident KPH Estimated speed of Other vehicle just before the accident KPH What was the condition of the road?

Sealed Unsealed Smooth Rough Wet Dry

How was visibility? Good Moderate Poor

Were there any witnesses to the accident? Yes No If Yes, please provide names and addresses

Did Police attend the accident? Yes No

If Yes, Police Station Name or No. of Police Officer

If No, state time, date, place reported to Police

Did police indicate who was responsible? Yes No If Yes, Name of Driver

Did police charge either driver or suggest action may be taken? Yes No Charge

Page 5 of 6

ACCIDENT DETAILS (continued)

Name of Other Driver Age

Phone No. Licence No.

Vehicle Make & Model Rego. No.

Name of Registered Owner Address

Phone No.

The Other Insurance Company Policy Number Description of Damage

VEHICLE OR PROPERTY NO. 1 VEHICLE OR PROPERTY NO. 2 DAMAGE TO OTHER VEHICLE OR PROPERTY

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Was anyone injured in the accident? Yes No

The information and answers given above are true in every detail and no information has been withheld.

Driver’s Signature Date

Insured’s Signature Date

NAME TYPE OF INJURY INJURED PARTY

(PASSENGER/DRIVER

VEHICLE (REGISTRATION NO.) PERSONAL INJURIES

DECLARATION

FOR MORE INFORMATION PLEASE

Contact your IBNA Insurance Broker

ZURICH AUSTRALIAN INSURANCE LIMITED ABN 13 000 296 640, AFS Licence No. 232507

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